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INDONESIA Work Plan FY 2017 Project Year 6 October 2016–September 2017

ENVISION is a global project led by RTI International in partnership with CBM International, The Carter Center, Fred Hollows Foundation, Helen Keller International, IMA World Health, Light for the World, Sightsavers, and World Vision. ENVISION is funded by the US Agency for International Development under cooperative agreement No. AID-OAA-A-11-00048. The period of performance for ENVISION is September 30, 2011 through September 30, 2019. The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

ENVISION FY17 PY6 Indonesia Work Plan

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ENVISION PROJECT OVERVIEW

The U.S. Agency for International Development (USAID)’s ENVISION project (2011–2019) is designed to support the vision of the World Health Organization (WHO) and its member states by targeting the control and elimination of seven neglected tropical diseases (NTDs), including lymphatic filariasis (LF), onchocerciasis (OV), schistosomiasis (SCH), three soil-transmitted helminths ([STHs] roundworm, whipworm, hookworm), and trachoma. ENVISION’s goal is to strengthen NTD programming at global and country levels and support ministries of health (MOHs) to achieve their NTD control and elimination goals.

At the global level, ENVISION—in close coordination and collaboration with WHO, USAID, and other stakeholders—contributes to several technical areas in support of global NTD control and elimination goals, including:

drug and diagnostics procurement, where global donation programs are unavailable

capacity strengthening

management and implementation of ENVISION’s Technical Assistance Facility (TAF)

disease mapping

NTD policy and technical guideline development

NTD monitoring and evaluation (M&E).

At the country level, ENVISION provides support to national NTD programs by providing strategic technical and financial assistance for a comprehensive package of NTD interventions, including:

strategic annual and multi-year planning

advocacy

social mobilization and health education

capacity strengthening

baseline disease mapping

preventive chemotherapy (PC) or mass drug administration (MDA)

drug and commodity supply management and procurement

program supervision

M&E, including disease-specific assessments (DSAs) and surveillance.

In Indonesia, ENVISION project activities are implemented by RTI International.


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TABLE OF CONTENTS Page ENVISION Project Overview .......................................................................................................................... 2

List of Tables ................................................................................................................................................. 4

List of Figures ................................................................................................................................................ 4

Acronyms List ................................................................................................................................................ 5

Country Overview ......................................................................................................................................... 6

1) General Country Background ............................................................................................................ 6

a) Administrative Structure ............................................................................................................... 6

b) NTD Program Partners .................................................................................................................. 7

2) National NTD Program Overview ...................................................................................................... 8

a) Lymphatic Filariasis ....................................................................................................................... 8

b) Schistosomiasis ........................................................................................................................... 11

c) Soil-Transmitted Helminthiases .................................................................................................. 11

3) Snapshot of NTD status in Indonesia .............................................................................................. 12

Planned Activities ........................................................................................................................................ 13

1) NTD Program Capacity Strengthening ............................................................................................ 13

a) Strategic Capacity Strengthening Approach ............................................................................... 13

b) Capacity Strengthening Interventions ........................................................................................ 14

2) Project Assistance ........................................................................................................................... 15

a) Strategic Planning ....................................................................................................................... 16

b) Advocacy for Building a Sustainable National NTD Program ...................................................... 17

c) Social Mobilization to Enable NTD Program Activities ............................................................... 18

d) Training ....................................................................................................................................... 20

e) Mapping ...................................................................................................................................... 22

f) MDA Coverage and Challenges ................................................................................................... 22

g) Drug and Commodity Supply Management and Procurement .................................................. 24

h) Supervision .................................................................................................................................. 24

i) M&E ............................................................................................................................................ 25

3) Maps................................................................................................................................................ 29

Appendix 1. Work plan Activities ................................................................................................................ 33


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LIST OF TABLES

Table 1. Administrative and health structure in Indonesia .......................................................................... 6

Table 2. NTD partners working in Indonesia, donor support, and summarized activities ........................... 7

Table 3. Snapshot of the expected status of the NTD program in Indonesia as of September 30, 2016 ... 12

Table 4. Project Assistance for Capacity Strengthening ............................................................................. 14

Table 5. Social mobilization/communication activities and materials checklist for NTD work planning ... 20

Table 6. USAID-supported coverage results for FY15 and targets for FY17 ............................................... 24

Table 7. Planned DSAs for FY17 by disease................................................................................................. 27

LIST OF FIGURES

Figure 1. Survey results from most recent TAS per EU, January 2011-June 2016 ...................................... 10

Figure 2. Indonesia province reference map .............................................................................................. 29

Figure 3. Indonesia LF and STH endemicity maps ....................................................................................... 30

Figure 4. Indonesia LF and STH MDA geographic coverage maps .............................................................. 31

Figure 5. FY17 planned DSA for LF .............................................................................................................. 32


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ACRONYMS LIST

ALB Albendazole BBTKL National Environmental Health Laboratory, MOH BELKAGA MDA Distribution Month BINPHARM Directorate General of Pharmaceuticals and Health Supplies, MOH CY Calendar Year DEC Diethylcarbamazine Citrate DEKON Special GOI funding to support national programs at the lower levels (Dekonsentrasi) DHO District Health Office DOT Directly Observed Treatment DQA Data Quality Assessment DSA Disease Specific Assessment FOG Fixed Obligation Grant FTS Filariasis Test Strips FY Fiscal Year GOI Government of Indonesia GSK GlaxoSmithKline HC Health Center ICT Immunochromatographic Test IEC Information, Education, and Communications JRSM Joint Request for Selected PC Medicines LF Lymphatic Filariasis M&E Monitoring and Evaluation MDA Mass Drug Administration Mf Microfilaria MOH Ministry of Heath NGO Nongovernmental Organization NTD Neglected Tropical Disease NTF National Task Force OV Onchocerciasis PC Preventive Chemotherapy PHO Provincial Health Office PSA Public Service Announcement RPRG Regional Program Review Group RTI Research Triangle Institute SAC School Aged Children SAE Serious Adverse Event SCH Schistosomiasis SEARO South East Asia Regional Office, WHO STH Soil-Transmitted Helminths Subdit Subdirectorate for LF and Helminthes Control, MOH TAS Transmission Assessment Surveys TIPAC Tool for Integrated Planning and Costing UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization


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COUNTRY OVERVIEW

1) General Country Background

a) Administrative Structure

Indonesia is the fourth largest country in the world, with a population of over 255 million people spread throughout 13,000 islands. Following years of restructuring, Indonesia currently is divided into 34 provinces and 514 districts. The Indonesia administrative and health structure related to the management of the national neglected tropical disease (NTD) program is summarized below (Table 1).

Table 1. Administrative and health structure in Indonesia

Level Bahasa Indonesia term

Head official Related health structure

National Negara Presiden Ministry of Health, Subdirectorate for Control of Lymphatic Filariasis, Soil-Transmitted Helminths, and Schistosomiasis

Provincial Provinsi Gubernur Provincial Health Office

District Kabupaten – rural Kota – urban

Bupati Walikota

District Health Office

Subdistrict Kecamatan^ Camat Health center (“puskesmas”)

Village Desa – rural Kelurahan – urban

Kepala Desa Lurah

Health post (“posyandu”)

Hamlet Rukun Warga --

^ In Papua and Papua Barat, this level is called a “distrik.”

The Subdirectorate for Control of Lymphatic Filariasis and Soil-Transmitted Helminths (Subdit), a unit within the Directorate General of Disease Control and Environmental Health of the Ministry of Health (MOH), is the lead for lymphatic filariasis (LF), soil-transmitted helminths (STH), and schistosomiasis (SCH) activities. A National Task Force (NTF) exists to oversee NTD policy, plans, and activities. It consists of MOH staff, ex-MOH staff, and academics, with multilateral agency representatives (World Health Organization [WHO], United Nations Children’s Fund [UNICEF]) invited as observers. The NTF meets at least once a year to discuss specific issues and provide technical recommendations for improving the LF, STH, and SCH programs.

At the national level, the Subdit is responsible for determining policies and procedures for program implementation, supervising and mentoring lower level staff, and monitoring and evaluation (M&E), as well as for procurement of drugs and operational supplies such as rapid diagnostic tests. The provincial level is responsible for supervision and M&E, and each province has a small budget to fund these activities. District governments are required to provide operational budgets for LF and STH mass drug administration (MDA), including training, drug distribution, and monitoring, and are directly responsible for program implementation in their respective areas. Beginning in calendar year 2015 (CY2015), the MOH has been able to provide limited funding for LF/STH MDA through a special mechanism from the central level, called “dekonsentrasi” (DEKON), which can augment local district budgets as needed.


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b) NTD Program Partners

Indonesia has only a few organizations involved in funding NTD work, with the United States Agency for International Development (USAID) and WHO the largest contributors (Table 2). WHO provides support for LF transmission assessment surveys (TAS), strategic meetings, and supervision, as well as for SCH elimination. Since the beginning of the LF MDA program, the MOH has accepted donations of albendazole (ALB) from GlaxoSmithKline (GSK) through WHO. In CY2016, following budget cuts, the Indonesia MOH accepted a large donation of diethylcarbamazine citrate (DEC) tablets from Eisai Company, Ltd., of Japan, through WHO to provide the Ministry the necessary drugs to expand programmatic support to more endemic districts, which included all of the USAID-funded districts. This support from WHO/Eisai will be reduced in CY2017, due to need to comply with MOH regulations regarding use of locally made pharmaceuticals. However, the MOH budget likely will not be enough to support local procurement for all districts implementing LF/STH MDA in 2017, so some donated DEC will have to be requested, particularly to support USAID districts.

For STH-only MDA, the MOH procures its own ALB for distribution. UNICEF provides limited technical support for the distribution of ALB to preschool children through the Vitamin A program. Two new prospective NTD partners, Vitamin Angels and Evidence for Action, are in the process of exploring possibilities to provide assistance to the MOH, specifically for STH, following preliminary discussions with the Subdit.

Table 2. NTD partners working in Indonesia, donor support, and summarized activities

Partner Location

(Regions/States) Activities

Is USAID providing direct financial support to this partner? (Do not include fixed obligation

grant [FOG] recipients)

List other donors supporting these

partners/activities

RTI/ENVISION Indonesia

Jakarta, with field support visits to implementing provinces/districts

Provide direct technical assistance to the Ministry of Health (MOH) in strategic planning, monitoring and evaluation (M&E), advocacy, and capacity building

Yes --

Supports mass drug administration (MDA) implementation in 51 districts through local non-governmental organizations (NGOs) in October 2016 and in 32 districts through local NGOs in preparation for October 2017.

Yes --

MOH Central, province, district

Lymphatic filariasis (LF)/soil-transmitted helminth (STH) MDA support in ~140 districts in CY2016 implements advocacy, M&E, and limited capacity building activities. Drug procurement of (DEC) (LF/STH MDA) and albendazole ([ALB] STH-only MDA), and Brugia Rapid test procurement for

No WHO Evidence Action (potential)


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Partner Location

(Regions/States) Activities

Is USAID providing direct financial support to this partner? (Do not include fixed obligation

grant [FOG] recipients)

List other donors supporting these

partners/activities

transmission assessment survey (TAS).

WHO Jakarta with field visit to implementing provinces/districts

Provides technical and financial support for strategic planning, M&E and donation/importation of ALB (2016, 2017), DEC (2016), and filariasis test strips (2017)

No GlaxoSmithKline, Eisai, Gates Foundation

Provides financial and technical support for the elimination activities of schistosomiasis in two endemic districts

Own funding

Vitamin Angels Jakarta with field visit to implementing provinces/districts

Possible provision of ALB for STH-only MDA for preschool children through a network of NGO health clinics (In discussion)

No Own funding

Evidence Action

Jakarta with field visit to implementing provinces/districts

Possible technical assistance for strategic planning, monitoring, and capacity building for STH-only school-aged children MDA (in discussion)

No Own funding

2) National NTD Program Overview

a) Lymphatic Filariasis

In 2005, the Government of Indonesia (GOI) decreed filariasis elimination to be one of the national priorities to combat communicable diseases and agreed to the global WHO goal of eliminating LF as a public-health problem by 2020. All three types of lymphatic parasites—namely Wuchereria bancrofti, Brugia malayi, and Brugia timori—are prevalent in Indonesia, with B. malayi the most widespread. Currently, 64 million people require LF MDA, with 14,932 chronic cases of either lymphedema or hydrocele reported. One district remains to be remapped using mini-TAS by the end of September 2016.

Program Goal The integrated NTD Plan of Action 2016–2020 includes an ambitious goal of reaching 100% geographic coverage of LF MDA in 2016 in order to achieve elimination of LF as a public health problem by 2020. Strategies follow the latest WHO guidance for LF (primarily guidance outlined in the 2011 TAS manual), although debate continues among national and international experts as to whether M&E in Brugia spp. areas should be done by microfilaria or antibody testing. As a step towards having the resources to scale up LF/STH MDA to full geographic coverage, the NTD Plan of Action 2016–2020 proposes a comprehensive LF MDA campaign plan, which includes a rapid scale-up of MDA as well as the designation of October as Bulan Eliminasi Kaki Gajah (BELKAGA) or “LF elimination month,” instead of having districts implement MDA on their own schedules. The MOH and the Ministry of Internal Affairs


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are finalizing a Presidential Regulation for LF MDA, focusing on achieving 100% geographic coverage by 2016 and elimination of LF as a public health concern by 2020, which enables the District Health Office (DHO) to access district-level funding for LF MDA operational costs.

The key challenges for the program in fiscal year 2017 (FY17) include:

- Meeting the 100% geographic coverage goal

- Ensuring quality drugs are available in a timely fashion

- Significantly increasing compliance

- Ensuring sustainable district-level budgets for MDA

Mass drug administration A total of 71.64 million people live in 198 districts requiring LF MDA, while 21.3 million people live in 28 districts currently in post-MDA surveillance. In CY2015, LF/STH MDA reached 36.2 million people in 144 LF-endemic districts. While the GOI had planned for 100% geographic coverage in 2016, two issues might hinder their ability to achieve this goal. First, following a recent cut in the special DEKON funds in 2016, there is a gap in financing available for CY2016 MDA. In order to increase district support for LF/STH MDA and close this gap, the Subdit has conducted several advocacy meetings at provincial and district levels and has received a commitment from all LF-endemic districts to implement LF/STH MDA in CY2016. Despite this commitment, concerns remain about the quality and coverage of the MDA in many areas due to lack of sufficient resources. Second, the local procurement of DEC has been delayed and this might delay the timing of LF/STH MDA.

While districts in Indonesia often report effective epidemiological coverage for LF/STH MDA, recent surveys have shown that there can be a marked difference between reported coverage and actual proportion of people ingesting drugs. This compliance problem is common in Asia, where directly observed treatment (DOT) is not always enforced, and presents a huge challenge for the Subdit in terms of changing health personnel and community attitudes towards the importance of DOT during MDA.

TAS Since 2009, 54 districts have implemented TAS1 to determine whether MDA can be stopped (including one district that implemented a re-TAS1); 28 are currently in the post-MDA surveillance phase (Figure 1). Of those 54 districts that have implemented TAS1, 39 (64%) have passed. Of 28 districts that have implemented TAS2, 18 (72%) have passed. One district has implemented TAS3 and failed; WHO has recommended a repeat TAS be done, as well as collection of dried blood spots for ELISA testing, to better understand the conflicting results between the original TAS3 results and the results from children who were positive during TAS3 but negative on follow up.

Given challenges with interpreting TAS results in Brugia spp. areas in Indonesia, a TAS Expert Meeting was held in March 2016 to provide Indonesia with specific guidance. The experts recommended that the critical cut-off in Brugia spp. areas, which use antibody tests to determine prevalence, should remain the same as that recommended in the TAS manual and that the MOH should use TAS checklists to better prepare and supervise TAS, as well as investigate TAS failure. A set of operational research questions was also proposed for investigation, including (1) determining the impact of animal transmission in zoophilic Brugia spp. areas, (2) determining age-prevalence curves by collecting Brugia Rapid results and dried blood spots during pre-TAS, and (3) reliability testing of Brugia Rapids by four international laboratories.


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Figure 1. Survey results from most recent TAS per EU, January 2011-June 2016

In FY16, 11 districts will have implemented TAS (TAS1=6, TAS2=5, TAS3=0). In FY17, 17 districts are planning to implement TAS. Five districts will implement TAS1, 4 districts will implement TAS2, and 8 districts will implement TAS3. FY17 mainly will be focused on pre-TAS assessments, with 40 planned to determine eligibility for TAS.

USAID support USAID support started in FY2011, with financing of LF/STH MDA in 13 districts, scattered throughout the country. After a review of LF endemicity and MDA data, ENVISION scaled up LF/STH MDA in FY2012 and FY2013, mostly in Sumatra, to help the MOH reach full geographic coverage in that region. ENVISION will support CY2016 LF/STH MDA activities in October 2016, via local nongovernmental organizations (NGOs) in 51 districts, including 7 new districts in Sumatra. Six of these districts are implementing MDA for the first time, while one district has already implemented one round of MDA with DEKON funding. For CY2017 LF/STH MDA, ENVISION will continue its support for 30 districts and will include additional funding for two other districts, to be named later, that may fail pre-TAS or TAS in FY17.

Past ENVISION support has focused on completing LF mapping so that the MOH can accurately estimate the burden of disease, plan advocacy measures with districts to support LF/STH MDA, and advocate to other donors and to the GOI for support. ENVISION has provided capacity building for (1) MDA implementation at national, district, and village levels in 51 districts; (2) mapping of LF; (3) TAS at


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national, provincial, and district levels; (4) data quality assessment (DQA) and an integrated NTD database at the national level; and (5) overall LF/STH policy and strategies at national, provincial, and district levels. ENVISION has also provided support to the MOH in implementation of LF sentinel and spot-check site assessments, TAS, DQA, and data review.

b) Schistosomiasis

Indonesia’s goal is to eliminate SCH, caused by Schistosoma japonicum, as a public health problem by 2020, following a strategic plan created with WHO assistance. The strategy includes surveys and treatment of humans, vectors (snails), and animal reservoirs (rats, cattle, and dogs).

SCH is endemic in Poso and Sigi districts in Central Sulawasi province, with an at-risk population of 22,600 people. Control activities ended in 2005; however, in 2010 Kato-Katz surveys showed a resurgence of transmission with an average prevalence of infection of 3.81% (range: 0–12.33) in 21 sites in the two districts. These areas have restricted access to potable water and sanitation, and few families have latrines. Although targeted MDA took place from 2010 to 2014, surveys in 2014 showed an increase in average prevalence from 0.80% in 2011 to 1.61% in Sigi and from 0.64% to 0.82% in Poso. Selective treatment (test and treat positives and family members) was provided to 6,720 people in 2015 in at-risk communities. The MOH provides the funding for the distribution and procurement of praziquantel. Currently, the program has gaps in funding for surveys and treatment of animal reservoirs.

ENVISION has not supported SCH activities in the past.

c) Soil-Transmitted Helminthiases

In 2012, the MOH released a new STH policy. It states that all districts should implement one annual round of STH MDA in preschool and school-age children (SAC), unless districts have evidence showing the need for no treatments or two annual treatments. The plan’s goal is MDA coverage of at least 75% of preschool children and SAC in all endemic districts by 2020. It is based, in part, on strategies in the WHO STH Strategic Plan and in the Deworming for School-Aged Children manual, although it also recommends district-level population-based cluster surveys for measuring prevalence and intensity. In districts without LF/STH MDA, STH-only MDA for preschool children is being scaled up to be delivered through the Vitamin A or National Weighing programs, while STH-only MDA for SAC is implemented through the Directorate of Child Health Support’s school health program in primary schools.

Indonesia has one of the highest numbers of children requiring preventive chemotherapy (PC) for STH in the world. In the last 15 years, 173 districts have been surveyed in Indonesia to assess STH prevalence, involving over 40,000 individuals (mostly children). Results show that STH infection is widespread in the country, with an average of 28.12% prevalence (range: 0%–85%). This policy results in 19.9 million preschool children (1–4 years) and 40.1 million SAC (5–12 years) needing at least one round of MDA per year. In CY2014, LF/STH and STH-only MDA coverage was estimated to include approximately 18.6 million preschool and SAC at risk of STH. In CY2015, coverage of preschool and SAC with STH was approximately 31% due to LF/STH MDA as well as STH-only MDA in Bali, Nusa Tenggara Barat, Sulawesi Utara, Sulawesi Selatan, Jawa Tengah, Jawa Timur, and DI Yogyakarta provinces. Given delays with local procurement of ALB by the MOH, STH-only MDA has been slow to scale up.

ENVISION has provided technical assistance and a small amount of funding for advocacy and information, education, and communication (IEC) to kick-start STH-only MDA. The STH-only MDA will be fully supported by the MOH and Ministry of Education (MOE) after the first year of activities in each province.


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3) Snapshot of NTD status in Indonesia

Table 3 shows the expected status of each NTD program in Indonesia as of September 30, 2016.

Table 3. Snapshot of the expected status of the NTD program in Indonesia as of September 30, 2016

MAPPING GAP

DETERMINATION MDA GAP DETERMINATION

MDA ACHIEVEMENT

DSA NEEDS

A B C D E F G H I

Disease

Total no. of

districts in

country

No. of districts

classified as

endemic

No. of districts

classified as non-

endemic

No. of districts in need of initial mapping

No. of districts receiving MDA as of 09/30/16

No. of districts expected to be in need of MDA at

any level: MDA not yet started, or has

prematurely stopped as of

09/30/16

Expected no. of districts where

criteria for stopping

district-level MDA have been

met as of 09/30/16

No. of districts requiring DSA as of 09/30/16

USAID- Funded

Others

Lymphatic Filariasis

514

239 274* 0 51 139 0** 35^

Pre-TAS: 40^^ TAS1: 5 TAS2: 4 TAS3:8

Onchocerciasis N/A N/A N/A N/A N/A N/A N/A N/A

Schistosomiasis 2 512 0 0 2 0 0 0

Soil-transmitted helminths

514 0 0 51 271# 194 0 0

Trachoma N/A N/A N/A N/A N/A N/A N/A N/A

* Kota Balikpapan is planning to conduct mini-TAS in September 2016 to determine endemicity, thus it is not included in either column C, D, or E ** 9 districts are implementing pre-TAS and TAS (Subang, Donggala, Pidie, Buton, Kota Tangerang, Nias, Pasaman Barat, Aceh Jaya, and Melawi) and are not scheduled to implement MDA in 2016, they are not included in column F, G, or H. ^ Column H for LF includes 7 districts (Mappi, Kuantan Singigi, Agam, Kota Tidore Kepulauan, Pesisir Selatan, Deli Serdang, Hulu Sungai Utara) implementing TAS-1 between July–September 2016 and are assumed to pass. ^^ Pidie, Subang, and Donggala are waiting for pre-TAS results and are assumed to pass the pre-TAS. # 131 districts in Bali, Nusa Tenggara Barat, Sulawesi Utara, DI Yogyakarta, Jawa Tengah, Jawa Timur, and Sulawesi Selatan provinces should be implementing STH-only MDA in calendar year 2016 Due to reporting timeframe and budgetary reasons, FY17 workbooks capture CY2016 LF/STH MDA for GOI-funded districts, FY2017 LF/STH MDA for USAID-funded districts, and CY2017 STH-only MDA for GOI-funded districts.


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PLANNED ACTIVITIES

1) NTD Program Capacity Strengthening

a) Strategic Capacity Strengthening Approach

The Subdit’s goal is to have a fully functioning national NTD program in place before the end of the ENVISION project in 2019, including:

The majority of activities – if not all – funded from national and district budgets.

Implementation of quality MDA following established best practice including: participatory cadre training, sweeping as necessary, enforced DOT, targeted social mobilization, effective local supervision, and a responsive SAE management system at all levels.

Timely procurement and efficient management of drugs and other program supplies, such as test kits.

Effective collaboration on the organization of all pre-TAS and TAS with the BBTKL and provincial laboratories and health authorities.

An up-to-date, responsive, and efficient data management system that provides accurate evidence for all reporting.

To strengthen program management, ENVISION will engage in three major strategic approaches this year, responding to those areas above where ENVISION will have the most influence and therefore impact: 1) strengthening MDA quality nationally; 2) institutionalizing M&E capacity; and, 3) strengthening data use. These leverage ENVISION’s strengths, while recognizing the Subdit’s leadership role and better influence to address local issues such as advocating for local funds, addressing domestic drug procurement issues, and responding to SAEs.

Objective 1: Strengthen Program Capacity to Implement Quality MDA in All Districts: Special efforts will be made to assist the Subdit to consolidate the lessons learned and best practices from the “ENVISION experience” (please see box) and expand their use into the other non-ENVISION districts. ENVISION will continue to collaborate with the Subdit to improve the quality of MDA management in the 51 ENVISION-supported districts in CY2016,

The ENVISION Experience During the last five years, ENVISION has continually refined a comprehensive approach for the management of MDA in Indonesia which emphasizes:

Strong coordination/planning at the

DHO and health center levels

Participatory training for cadres, using

a cadre handbook and standardized

powerpoint presentation

Social mobilization by local influentials

supported by compelling IEC materials

and mass media

Continued emphasis on importance of

implementation of DOT

Training and guided practice in the use

of reporting forms at all levels, based

on WHO guidelines

Targeted supervision by provincial and

district staff at low performing health

centers using standardized checklists

Annual data review and planning

meetings, including multi-year analysis

and dissemination of MDA data by

health center


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with an emphasis on increased frequency and quality of supervision by the Subdit, partner NGOs and DHOs during implementation of the MDA, prioritizing visits to low performing health centers (HCs). During preparations for the CY2017 MDA, ENVISION will continue these efforts to improve the quality of MDA management by focusing on strengthening DHO and HC coordination meetings and cadre training through refined terms of reference, improved tools and more participatory presentations. The ENVISION approach will be shared with non-ENVISION districts through dissemination of an updated cadre training presentation and cadre handbook that emphasize key best practices. ENVISION will also support the expansion of the ENVISON experience by collaborating with the Subdit on the organization of provincial- level coordination meetings in priority non-ENVISION provinces and supporting increased supervision of critical activities in non-ENVISION areas.

Objective 2: Strengthen Interdepartmental Collaboration to Institutionalize M&E Capacity: ENVISION will continue to support the Subdit in the establishment of official relationships with appropriate units within the MOH such as the BBTKL and provincial health laboratories, as well as local universities, to implement the various NTD surveys required to document elimination and track control of those NTDs endemic in the country. To further strengthen the effectiveness of this partnership, ENVISION also will continue to provide on-the-job practice opportunities to selected staff from each of these units by including them in ENVISION-funded M&E activities in the coming years. The emphasis will be on ensuring the sustainability of these important M&E activities by helping the Subdit to collaborate with critical partners, which should then be able to share the responsibility for funding many of the required surveys in the future, once their relationships with the Subdit are formalized.

Objective 3: Strengthen Data Management and Use: ENVISION will also continue to assist the Subdit to improve the management and use of program data, including supporting the implementation of DQA recommendations to strengthen the comprehensive reporting system.,

b) Capacity Strengthening Interventions

Table 4 provides details on ENVISION assistance for capacity strengthening.

Table 4. Project Assistance for Capacity Strengthening

Project assistance area

Capacity strengthening interventions/activities How these activities will help to correct needs identified in

situation above

a. Strategic planning

Coordinating on comprehensive program management including strategic planning with the entire Subdit team by ENVISION

Provincial LF/STH MDA review and planning meetings in 3 non-ENVISION provinces

ENVISION project review and planning meeting

These activities will help strengthen national-level program management, and data analysis and share the ENVISION experience with non-ENVISION districts.

d. Social mobilization

Ensuring use of best practices in districts by providing LF MDA cadre handbook to priority non-ENVISION districts

This activity will help share the ENVISION experience with non-ENVISION districts.

e. Training (please see the Training section for specific training activities)

i. Supervision Supervisory visits by MOH for 2017 LF/STH

MDA support activities

This activity will help the Subdit share the ENVISION experience with non-ENVISION districts.


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j. Short-term technical assistance

Local consultant for TAS supervisor training This activity will help ensure the institutionalization of collaboration on M&E by training the staff of the critical units with the MOH, who will become active partners in implementing M&E in the future.

Objective 1: Strengthen Program Capacity to Implement Quality MDA in All Districts

ENVISION will meet with the Subdit and together review epidemiological coverage results, look at whether coverage has improved in districts, identify the remaining low performing districts and discuss reasons for poor performance with reference to the MDA best practices checklist. Experiences in addressing SAEs will also be discussed. The Subdit’s experience with the new handbook, the provincial MDA review and planning meetings, and supervisory trips will be discussed to identify whether the support ENVISION has been providing is appropriate and effective.

Objective 2: Strengthen Interdepartmental Collaboration to Institutionalize M&E Capacity

ENVISION will review with the Subdit progress towards building both the human capacity and the institutional collaboration needed to implement future TAS activities. The number of projected staff required will be compared to current numbers of trained staff and the quality of recent TAS surveys will be discussed, including a review of TAS checklists for preparation and supervision. Efforts made to increase the number of staff as well as the quality of TAS implementation will be discussed, reflecting on whether these are the appropriate partners, whether further efforts are needed to strengthen the partnership, and whether the current capacity strengthening approach is working. Objective 3: Strengthen Data Management and Use

ENVISION will also continue to engage the Subdit in regular discussions on the practical use of evidence for decision making, and review with them how the Subdit is applying the available evidence, including routine, periodic review of MDA coverage data as well as other program data generated through pre-TAS and TAS, the DQA and coverage surveys. Regular inquiries on the current status of the integrated data base will also continue, as well as requests for feedback on how the data base and other M&E tools could be made more user friendly.

2) Project Assistance

In FY17, USAID support to Indonesia’s national NTD program will continue through ENVISION. The Subdit will continue leading the planning and implementation process, with support from ENVISION at district, province, and national levels. Activities outlined in this work plan contribute to the following ENVISION objectives in support of the national program:

technical assistance and funding for NTD control and elimination activities

capacity development for NTD control and elimination

improved M&E for NTD program activities


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a) Strategic Planning

In FY16, ENVISION assisted the Subdit to finalize a new integrated NTD Plan of Action 2016–2020, using the tool for integrated planning and costing (TIPAC) to generate budget information, which has been adopted as the national strategy for the elimination of LF across the country. Indonesia is also in the process of preparing for CY2016 LF/STH MDA, including those districts supported by ENVISION. Several challenges remain, though, such as ensuring sufficient local funding is available for implementation in each district following recent budget cuts and arranging for adequate drugs supplies after delays in the procurement process.

Provincial LF/STH MDA Review and Planning Meetings in Three Provinces: Based on the successful experience of implementing annual project review and planning meetings for ENVISION-supported districts, in preparation for the 2016 LF/STH MDA the Subdit has organized similar coordination meetings in other non-ENVISION provinces as they strive for 100% geographic coverage. Due to major budget cuts expected in 2017, the Subdit has requested assistance from ENVISION to help expand the implementation of these meetings into three high-priority, non-ENVISION provinces, Kalimantan Barat, Kalimantan Timur, and Kalimantan Tengah. These meetings will include extensive review of the coverage data (district and HC levels) from the CY2016 LF/STH MDA for all endemic districts in the three provinces, discussions on promoting DOT, improved supervision and better management of SAEs, and detailed planning for the upcoming LF/STH MDA in October 2017. Approximately 45 participants will attend the meeting in each province, including key staff from the Provincial Health Offices (PHOs), two participants from each of the DHOs in the province, and other important local stakeholders, as well as Subdit and ENVISION staff. These two-day meetings will be held in each of the three provinces from January through March 2017. These meetings will facilitate the planning and coordination of preparations for the MDA in these provinces by coordinating planning based on active dialogue among the relevant players at all levels. By funding and helping facilitate these meetings, ENVISION will be able to contribute more to the planning and implementation of the DHO activities, and help promote more participatory approaches.

These provincial coordination meetings are the most efficient way to update and engage the staff from the 27 DHOs that will be involved (Kalimantan Tengah with 11 DHOs; Kalimantan Timur with 7 DHOs, and Kalimantan Barat with 9 DHOs) who have the direct responsibility for organizing the MDA in their respective areas, as well as reinforce the PHO support and supervision network within each province. The Subdit will be responsible for follow up in terms of planning, implementation, and supervision of MDA in these districts. Reported coverage of the 2017 LF/STH MDA in each district will then be fed back to the PHO and DHOs during the provincial coordination meetings in 2018.

ENVISION LF/STH MDA Project Review and Planning Meeting: The three-day ENVISION LF/STH MDA Project Review and Planning Meeting is planned for February 2017. The participants of the meeting include the Subdit staff, two DHO staff from each of the 32 ENVISION-supported districts, the LF focal points from the PHOs in the associated 10 provinces, and the staff from the partner NGOs, as well as representatives from WHO and USAID/Indonesia. The purpose of this meeting will be to evaluate CY16 LF/STH MDA activities, including extensive review of all relevant data and sharing best practices and lessons learned. Data gathered through the partner NGOs on social mobilization and MDA supervision will be presented together with the MDA coverage data (both district and HC levels) during the review meeting. The data will form the basis to determine more effective, practical mechanisms to achieve the targeted coverage rates in 2017 as well as to promote DOT and improve the management of SAEs. A total of 150 participants will be included in this two-day meeting.


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LF/STH MDA District Coordination Meetings: During May and June 2017, district coordination meetings will be organized by the DHO with relevant local stakeholders to secure annual district-level commitment for social mobilization and cadre training activities as well as for the successful implementation of the LF/STH MDA. ENVISION will finance district coordination meetings in each of the 32 ENVISION-supported districts. ENVISION will also support the travel expenses for NGOs to attend these meetings and will provide a standardized MDA data template for presentation and discussion. These meetings will also be used to plan district-level support activities for the LF/STH MDA and to coordinate schedules and responsibilities.

LF/STH MDA Health Center Coordination Meetings: After the district coordination meeting, an HC coordination meeting will be organized in each HC within the ENVISION-supported districts during June and July 2017. Participants will include heads of villages and representatives from health posts as well as other sectors. The objectives of these meetings will include the review of timelines for all supporting activities; discussions on how best to promote increased social mobilization, implementation of DOT, and improved SAE management; and the organization of the upcoming MDA. ENVISION will help finance these meetings in districts where this is an identified financial gap.

Meetings to Develop Enhanced MDA Strategies with 10 Low-Performing Districts: As discussed in the MDA section, ENVISION is using the results of CY2015 MDA reports and associated coverage surveys to help districts better plan and implement CY2016 MDA. However, despite these efforts, in certain areas wide-spread and immediate change is not realistic and will most likely require both more time and more creative approaches. In order to better assist low-performing districts to identify more effective strategies for achieving established coverage targets, ENVISION will organize special planning meetings in each of the ENVISION-supported districts that is unable to reach 65% epidemiologic coverage during the October 2016 LF/STH MDA, or that has failed a pre-TAS or TAS. During these meetings, comprehensive analysis of all available data will be discussed (using the TAS failure checklist if appropriate), possible reasons for low performance will be determined, and appropriate strategies to respond to the local situation in each area will be developed. These strategies may include activation of the local network of religious leaders, more effective utilization of local media, the development of more compelling IEC materials using the local language, additional training for cadres, training of additional cadres, increased involvement by local village heads and village midwives, and/or more active supervision by all levels. These two-day meetings will include approximately 30 participants from the DHO, selected HCs, and selected villages, together with NGO and ENVISION staff. Once participants arrive at a consensus on recommended strategies, the individual strategies will be finalized during the ENVISION Project Review and Planning Meeting.

NTD Secretariat Office Supplies and Operational Cost Support: ENVISION will continue to provide limited funds for the MOH operational costs, including monthly internet and national mobile phone service within Indonesia for the Subdit. This will allow the Subdit to continue to engage the current high bandwidth internet service provider necessary to access and share the large amounts of data needed to maintain the M&E database and program files. ENVISION will also provide small amounts for stationery and office supplies.

b) Advocacy for Building a Sustainable National NTD Program

The Subdit is responsible for coordinating all advocacy efforts in support of the national NTD program in Indonesia. While the Subdit has been successful in working with the Ministry of Internal Affairs to issue a Presidential Regulation for the national NTD program, which will stimulate support for and increase status of the NTD program at lower levels, this regulation is not final yet. The Subdit has advocated for


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increased provincial- and district-level funding for the LF/STH MDA in all endemic districts, as well as for the establishment of a special national-level budget to support program activities in districts where budget gaps still exist. Although sufficient funding was originally allocated in the special DEKON budget, following recent cuts in both the special DEKON funding and routine operational funds, many districts may have trouble finding sufficient funding to implement high-quality MDA. Further advocacy efforts by the Subdit are needed to ensure that sufficient budgets continue to be allocated each financial year to maintain geographic coverage, though the Subdit has little influence on attempts by the Ministry of Finance to balance the national budget or by the National Planning Board to reallocate development funding to respond to shifting national priorities.

Subdit is also committed to funding the increasingly large number of surveys required to determine when LF MDA may be safely stopped and for post-MDA surveillance as the program matures. However, the Subdit also recognizes the need to develop official relationships with several other government agencies such as the BBTKL and provincial health laboratories to support the extremely large number of surveys that will need to be implemented in the coming years in order to qualify for the validation of elimination of LF by WHO. ENVISION will continue to support these efforts to institutionalize these official relationships as explained in the M&E section.

c) Social Mobilization to Enable NTD Program Activities

In previous years ENVISION facilitated the development of a comprehensive communication strategy and the design and pre-testing of a large variety of IEC materials, including pamphlets, posters, banners, t-shirts, fact sheets, flip charts, pins, press releases, patient testimonials, radio spots, and television spots. ENVISION has also printed and distributed some of these materials, such as banners, registration books, cadre handbooks, posters, flip charts, and fact sheets, throughout the ENVISION-supported districts and has provided guidelines and templates to be used by non-ENVISION districts to print their own materials. Because of the previous saturation of these materials, and the increasing ability of districts to fund their own materials and social mobilization events, extensive assistance from ENVISION is no longer necessary.

Following discussions with the Subdit, ENVISION will focus on providing limited support for communications this year, as follows.

Revising, Printing, and Shipping of LF/STH MDA Cadre Handbook: Following extensive feedback from the field during supervision visits, one of the most appreciated and useful materials has been the Cadre Handbook, which was developed in 2014 and has been distributed in limited numbers to HCs in all ENVISION districts. Cadres use this handbook as a visual aid for discussion with households during MDA social mobilization. Following analysis of the results of the CY2015 LF/STH MDA coverage survey, the Subdit now realizes that the promotion of DOT is a critical priority, which has not been emphasized adequately in the current version of the handbook. A clearer explanation of side effects also is needed, as well as a more compelling rational for why five rounds of MDA are required to eliminate the disease. ENVISION will therefore facilitate the updating of the Cadre Handbook and subsequently the printing and distribution of additional copies to cadres both in the ENVISION-supported districts as well as priority non-ENVISION supported districts to ensure that this critical tool is widely available: approximately 50,000 copies, including buffer stocks, will be needed. While the original cadres handbook was carefully reviewed for technical content and local understanding by ENVISION HQ and Indonesia staff, all further revisions also will be carefully and systematically reviewed by ENVISION and the full approval of the Subdit will be obtained before printing and distribution.


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LF/STH MDA Public Service Announcement (PSA): In 2014 and 2015, ENVISION aired a PSA on national TV and on local TV in ENVISION districts to raise awareness of LF/STH as well as improve coverage in poor performing districts. To evaluate the reach of the PSA after CY2014 MDA, ENVISION added questions into a survey on LF/STH MDA best practices and compliance implemented in December 2014 by the University of Indonesia in three districts (one ENVISION-supported district—Kota Batam, and two non-ENVISION-supported districts—Agam and Kota Depok). The survey included 1,218 respondents and found that the PSA had a positive impact on awareness and behavior, with a significant association between seeing the PSA and complying with MDA, awareness of MDA, and influencing drug taking behavior in others. Depending on the district, between 22% and 49% of people reported they had seen the PSA.

Additionally, the analysis showed that people did not participate in the MDA because they were fearful or indifferent to taking the drugs, attributes that were associated with higher incomes and, in the case of indifference, higher education levels and being male. However, many of these respondents had not seen the PSA, perhaps because it was shown mostly on local TV. Because TV viewership usually is higher amongst the more educated in Indonesia, PSAs may be a good way to reach these non-participators, providing that the timing and channel are modified to be more appropriate to their viewing habits.

In advance of and during the CY2016 LF/STH MDA, ENVISION will air the PSA, concentrating on coverage on national stations at prime time. Due to low viewing of local stations, the MOH has previously decided that airing the PSA on a national station in Indonesia Bahasa would be more effective than translating to local languages and airing on local stations. Prior to the CY2017 LF/STH MDA, ENVISION will again contract with a local production house to revise the spot for the current year and purchase appropriate air time in advance of the MDA. Costs for airing the PSA in October 2016 and revising and airing the PSA prior to the October 2017 MDA are captured on the social mobilization tab in the budget. The PSA, which has been successfully used in previously years, has been thoroughly reviewed by ENVISION and has the full approval of the Subdit.

ENVISION will utilize several mechanisms to monitor and evaluate the utility of the cadre handbook and TV spots. Questions concerning the use of these materials are included in the standard supervisor checklist to be used by both the DHO and partner NGOs when they monitor the cadre training and implementation of the MDA in their respective districts (Table 5). Several questions concerning communications are already included in the post-MDA coverage survey, which will be used in 13 ENVISION districts in FY17, and additional questions will be added to collect more detailed information on the impact of these materials on both coverage and compliance. In additional, ENVISION will require the media placement agent to provide reports on the frequency and estimated viewership of the PSA during the campaign.


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Table 5. Social mobilization/communication activities and materials checklist for NTD work planning

Category Key messages Target

population

IEC strategy

(materials, medium, activity,

etc.)

Where/when will they be distributed?

Frequency

Is there an indicator/

mechanism to track this

material/activity? If yes, what?

Other comments

Mass Drug Administration (MDA) Participation

MDA will take place at the local drug post in October

Community members

TV Spot National TV 180 spots over 4 national TV stations

% of audience who recall seeing the spot in coverage survey, or during MDA supervision

The drugs provided are free and safe

# of times messages aired on TV during reference period (source: TV broadcast reports)

Some side effects are normal and they will pass

Drugs should be swallowed in presence of health worker/cadre

MDA Implementation

MDA will take place at the local drug post in October

Cadre Cadre Handbook

During cadre training

50,000 copies

% of cadre using handbook during MDA supervision

The drugs provided are free and safe

Some side effects are normal and they will pass. If side effects do not pass, go to the nearest HC.

When distributing drugs, ensure people ingest them in front of you

d) Training

Although ENVISION has been providing quality training for MDA implementers for several years, gaps still exist. Due to the routine turnover of program managers at all levels, and to the nature of the program, which requires only periodic attention, as well as to continuing refinements in the program strategy, it has been critical to provide training each year for the major players in the program. This training ensures that they have a comprehensive knowledge of the program and are fully prepared to manage their respective responsibilities. In particular, the Subdit recognizes the need to (1) clearly emphasize the importance of DOT at all levels of the health system, (2) better prepare cadres to


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proactively explain side effects of the drugs, respond to questions about potential adverse events and report and respond to adverse events, and (3) improve the abilities of health staff at all levels to fill out reporting forms. Training for the LF/STH MDA is a cascade process that starts with updating NGO and district LF focal points on new guidelines and materials at the ENVISION LF/STH MDA Project Review and Planning Meeting, who then train the health center staff, who then train the cadres.

NGO Training: In FY17, NGO training is planned as a two-day training, conducted back to back with the ENVISION 2016 LF/STH MDA Project Review and Planning Meeting. Over the past several years, ENVISION has been building local NGO capacity through training, site assessments, and on-the-job supervision, starting with training on USAID rules and regulations and a basic knowledge of LF, and continuing with training on data collection and analysis. In FY16, ENVISION focused on improving the quality of supervision by these partner NGOs, and emphasized the supervision of cadre training and MDA implementation at low-performing HCs. Discussions also included NGO responsibilities in reporting SAEs and how to help reduce the impact of concerns about SAEs in the community. In 2017, ENVISION will compete the NGO support and then will consult with the new NGO partners to identify areas of focus for the training, potentially including organizational capacity building, better communications, development of more strategic local responses, continued improvements in supervision and reporting, and methods of facilitating the implementation of DOT in all project areas. The aim is to ensure the local NGOs have the capacity to influence local health programs, assist with meeting coverage and compliance requirements, and find continuing funding after ENVISION ends. Approximately 18 participants will be involved.

LF/STH MDA Health Center Staff Training: In Years 3, 4, and 5, based on the results of the DQA, the project added one additional day to the district coordination meeting to facilitate training of HC staff in use of updated reporting forms. Because of the success of this training in bridging this communication gap in the field, ENVISION will continue this activity in FY17 with a strengthened focus on implementing DOT and on improved SAE management and reporting at the HC level, using the key messages from the cadre handbook. ENVISION will work with the Subdit to provide appropriate training for DHOs and NGOs, including how to incorporate more interactive discussions within the HC trainings to solicit input and empower the HCs to improve implementation in their respective areas. ENVISION also will provide the materials for the DHOs to train HC staff during the ENVISION Project Review and Planning Meeting. The importance of this training as well as the cadres’ training (described below) will be emphasized during the ENVISION Project Review and Planning Meeting. Several sessions of the Project Review and Planning Meeting will be devoted to sharing experiences and best practices among the NGOs and DHOs on how to adapt these trainings to better respond to the local situation in each area as well as to the capacity/experience of the trainees, and how to better use the evidence available to stimulate greater motivation. These ideas will be reinforced during visits by ENVISION staff to the low-performing districts for the district coordination meetings and during the regular discussions with NGO partners by telephone and email.

LF/STH MDA Cadre Training: Through local NGOs in the 32 districts where LF/STH MDA is being supported with USAID funding in FY17, ENVISION will ensure that all the cadres receive timely and adequate training on all aspects of the LF elimination program (Table 6). The training, which uses a standardized PowerPoint and pre-/post-tests, will emphasize the need to participate in the program, how to register the population and record treatments, supervised ingestion of the drugs, identification and treatment of side effects, and referral and referral of SAEs. The PowerPoint presentation has been recently revised and updated and now includes more colorful and attractive graphics as well as additional messages on DOT. The presentation has also been designed to encourage more interactive discussions and enhance the active participation of the cadres. Each HC will also be encouraged to adapt


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the presentation to local conditions using the local language, if appropriate, and/or local examples, and to include coverage data from each HC to further stress the need for both sweeping and DOT. Three HC staff overseeing the MDA campaign will conduct the training in each HC. The aim will be to train four cadres per health post. Over 95% of cadres are women, and this training aims to give them skills to become respected advocates for preventive health care in their communities.

While this will be refresher training for many of the cadres who were trained in previous years, the fact that LF/STH MDA only happens once a year necessitates refresher training annually in order to ensure cadres can adequately respond to the communities’ questions and report population registration and treatment coverage data correctly.

Each DHO and partner NGO will attend the cadre trainings in each low-performing HC in their district, as well as trainings in approximately 20% of the other HC, in order to monitor appropriate implementation using a training supervision checklist. ENVISION has already assisted the NGOs in prioritizing HCs for supervision, based on a comprehensive review of HC-level coverage data from past MDA years.

e) Mapping

All LF mapping and remapping for Indonesia has been completed by the Subdit, with considerable support from ENVISION, in 2016. No additional mapping is required this year.

f) MDA Coverage and Challenges

For October 2016 LF/STH MDA, ENVISION will provide support a total of 51 districts; four of these are starting round one of MDA in CY2016.

For October 2017 LF/STH MDA, ENVISION will support a total of 32 districts through FOGs.

The following are the major changes from the ENVISION support for the 51 districts for CY2016 MDA:

- 3 districts in Aceh were only provided emergency support for one MDA round in CY2016 and will not be supported for CY2017 MDA.

- 21 districts will be implementing pre-TAS instead of CY2017 MDA.

- 2 districts (Aceh Besar and Kutai Barat) are officially scheduled to implement pre-TAS in 2017 by the Subdit but the districts themselves are worried about the quality of their reporting and have requested support from ENVISION to implement an additional round of MDA in CY2017 in case they fail the pre-TAS; and therefore are currently included in plans for both a pre-TAS and MDA in CY2017.

- Therefore, 27 districts that received support from ENVISION for the CY2016 MDA will continue to receive support for the CY2017 MDA.

In addition, ENVISION will provide CY2017 MDA support for five other districts, as follows:

- 3 districts (Aceh Jaya, Melawi and Pasaman Barat) which previously received support from ENVISON for their MDA in CY2015, failed their pre-TAS in 2016 and will therefore require additional ENVISION support for their CY2017 MDA.

- 2 districts are unknown, but support is included in this work plan assuming that 2 ENVISION districts might fail pre-TAS or TAS and need CY2017 MDA.


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This also assumes that all 18 districts implementing final rounds of MDA in October 2016 will achieve sufficient coverage to be eligible for pre-TAS in FY17.

Support for MDA in October 2016: ENVISION has contracted with 10 partner NGOs through existing FOGs (June 2016 to December 2016) to provide technical assistance and fill in funding gaps for comprehensive LF/STH MDA implementation in 51 districts. These 51 districts are mainly on the island of Sumatra but also include a scattering of other districts across the Indonesian archipelago. Each FOG is developed together with the partner NGO and the respective DHO. The FOGs are designed to synchronize funding between the DHO and ENVISION to ensure that all necessary activities are sufficiently funded, but without overlap or duplication. Major activities funded in each FOG, either directly by ENVISION or through a DHO cost share, include coordination meetings at the district and HC levels, training in M&E, cadre training, community registration, social mobilization, MDA implementation, sweeping, and reporting and recording. Beginning in FY16, additional funding has also been provided to ensure stronger and more effective supervision by both the DHO and partner NGO to all low-performing HCs as well as a sample of other HCs in their area based on newly revised supervision check lists, particularly for key activities such as the cadre training as well as the actual MDA implementation.

Support for MDA Preparations before October 2017: In FY17, ENVISION will engage partner NGOs to provide continuing assistance to 32 districts (including the 2 to be named later), using the same approach and methodology, but with additional attention given to supervising and mentoring all low-performing HCs in their respective areas (Table 8). The NGOs will also be engaged to promote the implementation of DOT during all preparation activities and supervision visits.

Supplementary Support for Low-Performing Districts for 2017 MDA : The enhanced support for low-performing districts determined during meetings at the district level prior to the ENVISION Project Review and Planning Meeting (see Strategic Planning section above) will also contribute to improving the coverage and compliance rates in the four districts identified above as well as in the other districts that have failed pre-TAS or TAS and now require additional rounds of MDA.

All of the ENVISION activities planned for FY17 have been designed to respond to the specific challenges outlined throughout this work plan. ENVISION will evaluate the implementation of the MDA in all ENVISION-supported districts in collaboration with the respective NGO partner through:

increased supervision of MDA implementation in all low-performing HCs utilizing the newly revised supervision checklists

visits by ENVISION staff to priority districts during MDA preparations and implementation to directly evaluate effectiveness and provide assistance in problem solving

careful review of all MDA reports with direct follow-up on any delayed reporting,

implementation of coverage surveys in 13 districts to include more specific questions on distribution of drugs, locations, and compliance, including associated knowledge, attitudes, and practices


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Table 6. USAID-supported coverage results for FY15 and targets for FY17

NTD # Rounds of

annual distribution

Treatment target (FY15)

# DISTRICTS

# Districts not meeting epi coverage

target in FY15

# Districts not meeting program coverage

target in FY15

(FY15) #

Treatment targets

PERSONS

(FY15) # treated PERSONS

(FY15) % of

treatment target met PERSONS

FY17 treatment targets

# DISTRICT

S

FY17 treatment

targets # PERSONS

LF One 50 4 4 18,131,875 16,162,252 89% 30^ 9,714,333

STH One 50 4 4 5,353,181 4,787,699 89.4% 30^ 1,505,722

* FY17 treatment targets refer to October 2017 LF/STH MDA

^ Two districts will be named later and thus aren’t included in these numbers.

g) Drug and Commodity Supply Management and Procurement

Shipping of Drugs for LF/STH MDA to ENVISION-Supported Districts: In FY17, ENVISION will continue to be responsible for arranging the shipment of the required DEC and ALB drugs to each of the 32 ENVISION-supported districts, well in advance of the MDA.

Procurement of ICT/FTS to Support Pre-TAS in Supiori and Ende Districts: Due to very difficult geography in Supiori and Ende, Papua, which would make night blood collection impossible, as well as to be in accordance with the current international best practices, ENVSION will propose to use antigen testing during the pre-TAS in Supiori and Ende. Approximately 700 test kits per district may be procured through the Alere agent in Jakarta. As the new FTS is still undergoing review and has not yet been officially registered in Indonesia, Alere will most likely only be able to provide ICTs during FY17.

SAEs: Importantly, as part of the LF/STH MDA campaigns, the cadre and HC staff will monitor for SAEs and report and refer any patients with serious concerns to health professionals. The triage will initially be to local doctors/nurses, followed by the district or the provincial hospital if indicated. Cases of SAEs that are referred to the district hospital will be reported to the central MOH to monitor and to manage any negative impact. Training of provincial staff, district staff, and HC staff as well as cadres will include the updated modules/messages from the new global SAE guidance. In February 2016, during the BELKAGA review meeting, the Subdit directed each PHO to work with its DHO to establish district-level committees to manage all local SAEs that occur during the MDAs and organize any treatment that may be needed. The local DHO will be responsible for determining if engaging with local media is appropriate, and for making the necessary arrangements. ENVISION and our partner NGOs will continue to encourage districts to report any SAEs that might occur to the Subdit and to work with the Subdit to report any SAEs to RTI, WHO, GSK, and Eisai.

h) Supervision

Supervisory Visits by NGO and DHO Staff for 2016 LF/STH MDA Support Activities: To provide supervision assistance, the ENVISION partner NGOs will supervise and mentor the actual MDA supervision and sweeping activities in all of the 51 ENVISION-supported districts during the LF/STH MDA in October and November 2016. They will focus their attention on those HCs that have been identified as low performing based on their history epidemiological and program coverage numbers. The NGOs will also be responsible for supervising an additional 20% of the HCs in each district to ensure the maintenance of good program implementation. The NGO together with DHO staff will fill out monitoring


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forms and checklists to assess the implementation of the various components of the MDA; these are submitted and reviewed by ENVISION staff. Results from these checklists are presented at the ENVISION LF/STH MDA Project Review and Planning Meeting to highlight common issues, such as inconsistent use of DOT, misclassification of eligible people, and reasons for non-compliance. ENVISION staff will also review these supervisory checklists upon submission and discuss any critical issues with central MOH staff in order to provide feedback to the NGO and DHO on how to resolve the issues during future rounds of MDA.

Supervisory Visits by MOH for 2017 LF/STH MDA Support Activities: In preparation for the 2017 LF/STH MDA campaign, staff from the Subdit will be provided with funding from ENVISION to supervise selected activities in selected districts, both ENVISION-supported districts and non-ENVISION-supported districts, with an emphasis on those critical activities, such as district coordination meetings and cadre training in problematic areas where the national level staff can be most effective. Although the Subdit does have its own funding available for supervision, this limited amount is usually insufficient to cover all of the travel required to adequately supervise the national program. ENVISION will therefore provide support for approximately 20 trips of four days each for Subdit staff.

Supervisory Visits by DHO and NGO Staff for 2017 LF/STH MDA Support Activities : As in previous years, ENVISION will provide funding in the FOGs for the DHO and local partner NGO to supervise MDA preparation activities for the CY2017 MDA in each of their respective areas. Results from the CY2016 MDA will be used to determine priority HCs. Priority HCs will become the focus of intensive supervision by both the DHO and NGO staff during all critical preparation activities, such as the M&E training, the cadres training, HC coordination meetings, and registration. The DHO and NGO staff will also be supported to supervise a limited number of other HCs in their respective catchment areas in order to encourage best practices across each district.

Supervisory Visit by RTI ENVISION: RTI ENVISION will provide additional level supervision covering many areas that may not be reached by the DHO, PHO, and MOH. All RTI ENVISION staff use standardized supervision checklists or NGO assessment forms to collate information and include these in their trip reports.

i) M&E

Ongoing M&E Support: The ENVISION Indonesia Senior M&E Specialist and M&E Officer will continue to work together with the Subdit staff to support all M&E activities in the ENVISION work plan and assist with all related reporting.

Integrated NTD Database: During FY17, the ENVISION M&E Specialist and M&E Assistant will continue to work closely with the M&E focal person at the Subdit to build her capacity to sustain the database, and be on call at any time that technical assistance is required. This will include both regular meetings and additional on-the-job training on the integrated NTD database whenever a problem occurs, including ensuring a review of data received from the field and timely entry of data into the database.

Although the basic M&E strategy for the national NTD program has not changed, there is a continuing realization that the Subdit will need substantial help in implementing the huge and ever-increasing number of pre-TAS and TAS required as the program matures. Building on the TAS supervisory training in FY16, and with encouragement from ENVISION, the Subdit will continue to explore the possibility of establishing formal relationships with several other units within the MOH to share the responsibilities of implementing and funding all of these disease specific assessments (DSAs) in the future. Currently the most likely collaboration will be with the BBTKL and with provincial health laboratories. ENVISION has


26

included these units in last year’s TAS supervisor training and will do so again this year, as well as encourage the Subdit to actively involve the trained supervisors in the implementation of both the pre-TAS and TAS this year. It is critical that this collaboration be institutionalized and made formal as soon as possible to ensure adequate manpower and financial resources for the future.

LF/STH MDA Coverage Surveys: ENVISION will support a coverage survey in 13 CY2016 MDA districts, 7 of which will be implementing MDA activities for the first time under ENVISION and 6 of which have failed TAS and are implementing repeat MDA (re-MDA). The surveys will help confirm if reports of numbers of drugs distributed are valid and will collect information on the numbers people received and ingesting the drugs as well as their reasons for not complying. In 2017, additional questions will be added to collect information on where people are actually receiving the drugs to determine whether more supervision is needed during the sweeping phase of MDA. The questionnaires also will include simple questions, using clear photos, about whether people in the household have lymphedema or hydrocele in order to help fulfill LF dossier requirements on patient estimates.

ENVISION will engage a local university or research center to implement the survey following open competition, to implement the surveys in all 13 districts. Teams of experienced interviewers who have had previous experience in conducting interviews using mobile technology will be deployed and will work with both province- and district-level MOH personnel to implement the questionnaires. Once the data collection is completed, the research organization will analyze the data and submit a final analysis and report. They will also be asked to present the results to the Subdit and the relevant districts, which will then disseminate the results to the HCs in their area. All of this information will then be used to inform improvements in local strategies, communication efforts, and program management to ensure that future MDAs are of the highest quality possible.

LF Pre-TAS Sentinel and Spot-Check Sites: Based on the latest data review with the Subdit, ENVISION will support 23 of the 40 districts that have met the criteria of achieving at least five rounds of MDA with epidemiological coverage above 65%. The Subdit will support the other 17 districts from its own budget. For each pre-TAS, data will be collected from one sentinel site and one spot-check site per district. For the two pre-reTAS, data will be collected in four spot-check sites per district.

The sentinel and spot-check site assessments will be managed by the central level team, engaging laboratory technicians at the provincial and district levels. Results will be entered into the integrated NTD database and shared with the districts through a formal letter from the Subdit. Only districts that have a result of Mf < 1% or antigen < 2% will pass the pre-TAS and be considered for implementation of a TAS. Districts that do not achieve this cut off will be required to continue MDA for two additional rounds before implementing another pre-TAS.

LF TAS: In FY17, ENVISION will support 7 TAS in 7 districts/municipalities. These surveys will apply antigen testing with ICTs or FTS (if available) in W. bancrofti areas, or antibody testing with Brugia Rapid tests in Brugia spp. areas among SAC who are sampled according to WHO guidelines. All rapid diagnostics will be provided by the Subdit.

TAS will be conducted among first- and second-year primary school pupils (if >75% of children in the area attend school) or among children aged 6–7 years within the community (if <75% of children in the area attend school). The survey will use a cluster methodology.

In FY17, ENVISION will conduct TAS1 in 4 districts; TAS2 in 2 districts; and TAS3 in 1 district. The remainder of TAS planned for FY17 will be supported by Subdit or WHO funding. Each TAS will be implemented by a team consisting of one PHO staff, DHO staff, two HC staff, and two cadres per cluster, as well as a national level supervisor from the Subdit, BBTKL, regional health laboratories, and/or local


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universities, with assistance from ENVISION. In each district, there will be four teams implementing TAS simultaneously. The surveys will be implemented between November 2016 and September 2017. All surveys will utilize the newly developed TAS planning and supervisory checklists for each of the various components. In all areas, duplo testing (double testing) of all positive samples will be done, and any discordant results will be considered as “undetermined” and not included in the survey sample. Results and next steps will be shared with the districts through a formal letter from the Subdit. If any districts fail either the TAS2 or TAS3, ENVISION will work with the Subdit to submit a request to the WHO RPRG for advice on next steps, per the guidance in the 2011 WHO LF TAS manual and the 2016 LF TAS Expert Meeting in Jakarta.

For all ENVISION-supported districts that fail either a pre-TAS or a TAS, ENVISION will work with partner NGOs to work with the respective DHO and their HCs prior to the next round of MDA to (1) utilize the TAS checklists and in-depth data review to investigate the failure; (2) where possible, organize focus groups to collect information from cadres and/or community members; (3) enhance their local social mobilization strategy to include more local-specific activities, such as engage religious leaders or other influential people, provide media in the local language, or increase the funding for cadres to travel to all low-performing villages; (4) increase the promotion, implementation, and monitoring of DOT; and (5) increase the amount of active supervision of the HC, DHO, and NGO staff to low-performing areas to assist with local problem solving and increase local motivation. Table 10 shows DSA planned for FY17.

Table 7. Planned DSAs for FY17 by disease

Disease No. of endemic

districts

No. of districts planned for

DSA

Type of assessment

Diagnostic method

Lymphatic filariasis 238 40, with 23 by

ENVISION Pre-TAS Mf/ICT or FTS

Lymphatic filariasis 238 5, with 4 by ENVISION

TAS1 FTS/Brugia Rapid





Lymphatic filariasis 238 13, with 13 by

ENVISION Coverage Survey

n/a

Data Quality Assessment Follow Up: In FY16 Q4, ENVISION is conducting a DQA in two non-project-supported districts to assess the strengths and weaknesses of data management related to LF/STH MDA at health posts, HCs, DHOs, PHOs, and the national level. Based on these results, ENVISION will provide support to the MOH in early FY17 to help correct errors in the reporting and archiving procedures and will update the DHO and HC trainings as needed. To help the MOH continue to monitor and improve its data quality, ENVISION will support the implementation of another round of DQA, using the same WHO/RTI DQA protocol, in FY18.


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TAS Training for PHOs and DHOs: In FY17, staff from 27 districts planning TAS in CY2018 together with their provincial-level counterparts will have to be trained in TAS implementation, including eligibility, sampling, preparations, testing methodology, and interpretation of results. To help PHOs and DHOs understand the purpose of the surveys and the process, a three-day training on TAS methodology and how to use the appropriate rapid tests will be conducted, based on the WHO TAS training modules. A pre- and post-test will be used to evaluate the participants’ change in knowledge after training, as well as an assessment of their abilities to use and read the rapid diagnostic tests. ENVISION will fund, organize, and co-facilitate the training with the Subdit. Approximately 32 participants will attend the training, to be held in September 2017.

TAS Supervisor Training: The number of districts implementing post-MDA surveillance is growing each year. With limited personnel at the central and PHO levels to supervise pre-TAS and TAS activities (as has been done in the past), there is an increasing demand for new supervisors to be trained who can assist the Subdit in conducting the large number of surveys each year. In March 2016, ENVISION helped train 40 personnel from the BBTLK, selected provincial laboratories, and local universities and will include them in the implementation of all TASs organized in FY16. Because of the increasing number of TASs planned for FY17 and beyond, the need for more experienced TAS supervisors is clear. Therefore, ENVISION will support an additional training in March 2017 for approximately 40 more personnel from BBTKL, selected provincial laboratories, and local universities. These personnel will then be provided with extensive mentoring in the field by ENVISION and Subdit staff and will eventually become directly responsible for organizing and supervising individual TASs in their respective areas in the near future.


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3) Maps

Figure 2. Indonesia province reference map


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Figure 3. Indonesia LF and STH endemicity maps


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Figure 4. Indonesia LF and STH MDA geographic coverage maps


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Figure 5. FY17 planned DSA for LF

Note: Data for this map was from 29 July 2016 workbooks and the exact month of TAS implementation within CY2017 is currently being decided by the MOH. It is likely that some of the TAS supported by Government of Indonesia will move to FY18.


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APPENDIX 1. WORK PLAN ACTIVITIES

FY17 Activities

Project Assistance

Strategic Planning

Provincial LF/STH MDA review and planning meetings in 3 non-ENVISION provinces

ENVISION LF/STH MDA Project Review and Planning Meeting

LF/STH MDA district coordination meetings in 32 districts (FOGs)

LF/STH MDA health center coordination meetings in 32 districts (FOGs)

Meetings to develop enhanced MDA strategy with 10 low-performing districts

NTD Secretariat

NTD secretariat supply and operational cost support

Building advocacy for sustainable national NTD program

Social mobilization to enable NTD program activities

Revising, printing and shipping of LF MDA Cadre Handbook

LF/STH MDA public service announcement

Training

NGO training

2017 LF/STH MDA health center staff training (FOGs)

2017 LF/STH MDA cadre training (FOGs)

Mapping

MDA

Support for 2016 LF/STH MDA in October 2016 in 51 districts (FOGs)

Support for 2017 LF/STH MDA preparations before October 2017 in 32 districts (FOGs)

Supplementary support for low-performing districts (FOGs)

Drug Supply Management and Procurement

Shipping of drugs for LF/STH MDA to 32 districts

Procurement of ICT/FTS for pre-TAS in Supiori and Ende districts

Supervision

Supervisory visits by DHO and NGO staff for 2016 LF/STH MDA support activities (FOGs)

Supervisory visits by MOH for 2017 LF/STH MDA support Activities

Supervisory visits by DHO and NGO staff for 2017 LF/STH MDA support activities (FOGs)

STTA

Consultant for TAS supervisor training

M&E

Ongoing M&E technical assistance to Subdit

Integrated NTD database support

LF/STH MDA coverage surveys in 13 Districts (FOG)

LF pre-TAS sentinel and spot-check site surveys in 23 Districts

LF TAS in 7 districts

Data Quality Assessment follow up

TAS training for PHOs and DHOs

TAS supervisor training

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